Thread by @CharlesBHolmes

Americans are getting a crash course in novel therapies for #COVID19. This is a hotly debated topic, even among physicians. As we saw with hydroxychloroquine, the decisions Trump/his docs make affect what patients expect in their own care, so it’s worth talking about remdesivir.

Remdesivir is an antiviral originally developed to treat hepatitis C and later tried as a treatment for Ebola & Marburg. It didn’t work against those viruses, but it appears to have an effect on coronavirus (a good reminder that research on rare viruses can benefit us all)
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Initial data from clinical trials were promising enough that the FDA granted emergency use authorization on May 1 for use in severely ill COVID-19 patients. In August FDA expanded this to apply to any hospitalized patient (the category Trump apparently falls under).
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That being said, the beneficial effect of remdesivir appears to be modest. The best data we have so far suggests that it reduces hospital stays from 15 to 11 days but does not significantly reduce the odds of dying from COVID-19.
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nejm.org/doi/full/10.10…

Even with these limitations, doctors have largely embraced remdesivir for hospitalized COVID patients since there are few other options and it’s generally well-tolerated. Because it’s given by IV over 5 days, it’s not useful for patients who are well enough to remain at home.
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It’s also worth noting that remdesivir’s effects were most apparent in patients who were sick enough to require hospitalization AND supplemental oxygen. Right now Trump (reportedly) doesn’t fall into this category, so the clinical benefit for him may be more modest.
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Remdesivir is expensive at $3,120 per course (gov’t hospitals like Walter Reed pay a discounted rate of $2,340). With an avg COVID hospitalization cost of $14,000+, its cost effectiveness will vary based on pt characteristics + use of other drugs
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icer-review.org/announcements/…

As I discussed in my prior thread, current @IDSA guidelines recommend remdesivir if hospitalized COVID patients have severe illness (i.e. blood oxygen level ≤94% and those who require supplemental oxygen or more aggressive interventions).
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idsociety.org/practice-guide…

Trump reportedly doesn’t have severe illness (SpO2 96% this morning). But CDC data for COVID patients in his age group w/comorbidities are certainly concerning – 65% were hospitalized, and 32% died. This is probably why his docs are being so aggressive
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cdc.gov/mmwr/volumes/6…

In summary, Trump’s docs are going above & beyond the (still evolving) standard of care right now, either because he’s a VIP or because age/obesity/other conditions increase his risk. For now remdesivir appears to be a reasonable intervention w/ relatively few side effects.
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Today's press conference implied Trump has been symptomatic for 72 hours. Days 7-10 are often when patients deteriorate, but anything can happen before then. If he’s started on dexamethasone or oxygen in the next few days, that could be a sign his symptoms are worsening.
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Update: @peterbakernyt and @maggieNYT now reporting that Trump received supplemental oxygen on Fri at the White House for shortness of breath, which likely explains the transfer to Walter Reed, and the decision to start remdesivir - more to come in the days ahead